Module 7.2 (Individualized Anticoag Dosing)

What is the goal range for INR in warfarin therapy?

2-3

What does an INR <2 mean?

blood too thick

What does an INR >3 mean?

blood too thin

What is the normal INR level?

A. 0.5-1

B. 0.8-1.1

C. 2-3

D. 2.5-3.5

B. 0.8-1.1

How does smoking impact INR?

A. increases

B. decreases

B. decreases

If a patient eats an increased amount of vitamin K, how does that affect their INR?

A. increases

B. decreases

B. decreases

If a patient eats a decreased amount of vitamin K, how does that affect their INR?

A. increases

B. decreases

A. increases

How does acute alcohol intake affect INR?

A. increases

B. decreases

A. increases

How does chronic alcohol intake affect INR?

A. increases

B. decreases

B. decreases

In what situations is ASA + warfarin indicated? (select all)

A. s/p stroke

B. s/p ACS

C. patients with mechanical heart valve

D. patients with automatic heart valve

B. s/p ACS

C. patients with mechanical heart valve

NP is a 57 yo female presenting to the clinic for evaluation of cellulitis. The PCP has prescribed a 10 day course of Bactrim. NP has a PMH significant for Afib and diabetes. You have identified a potential adverse drug reaction. What would be the most appropriate intervention?

A. advise a warfarin dose decrease, with INR f/u in 5 days

B. increase glipizide to improve glucose control

C. recommend cephalexin which should have no interaction with warfarin

D. do nothing- Bactrim is only prescribed for 10 days

A. advise a warfarin dose decrease, with INR f/u in 5 days

In the setting of bactrim, warfarin dose is typically reduced by how much?

A. 10%

B. 25%

C. 50%

D. 75%

C. 50%

JJ has returned to your clinic for follow up after reducing his warfarin dose from 5mg to 2.5 mg while on Bactrim. His INR 5 days after starting Bactrim is 2. JJ reports no bleeding or bruising. What is the next step?

A. Increase warfarin dose back to 5 mg daily

B. stop bactrim

C. increase warfarin to 5 mg daily s/p completion of Bactrim, with INR f/u in 7 days

D. continue warfarin 2.5 mg daily since INR is therapeutic

C. increase warfarin to 5 mg daily s/p completion of Bactrim, with INR f/u in 7 days

FR has been on warfarin therapy for 3 years. Today he reports an increase in his vitamin K intake as he has decided to become a vegetarian. You have identified that the dose of warfarin is too low, given today's low INR in the setting of increased vitamin K intake. What would be the most appropriate intervention?

A. increase warfarin to 5 mg daily x 7.5 mg on M/F

B. increase warfarin to 10 mg daily

C. continue warfarin 5 mg once daily

D. decrease vitamin K intake back to normal

A. increase warfarin to 5 mg daily x 7.5 mg on M/F

note: for warfarin dose changes, changes in increments of 5-10-20% is better than doubling a dose

What do you have to check if a patient wants to switch from warfarin to a DOAC? (select all)

A. insurance

B. kidney function

C. CBC

D. INR

A. insurance

B. kidney function

C. CBC

D. INR

When switching from warfarin to a DOAC, when can you make the transition if the INR is less than 2?

ASAP

When switching from warfarin to a DOAC, when can you make the transition if the INR is between 2-2.5?

start the next

When can you start Rivaroxaban when a patient is switching from warfarin?

A. as soon as INR less than 1

B. as soon as INR less than 2.5

C. as soon as INR less than 3

D. as soon as INR less than 3.5

C. as soon as INR less than 3

When can you start edoxaban when a patient is switching from warfarin?

A. as soon as INR less than 1

B. as soon as INR less than 2.5

C. as soon as INR less than 3

D. as soon as INR less than 3.5

B. as soon as INR less than 2.5

When can you transition from heparin to a DOAC?

A. upon discontinuation (~2 hours)

B. when next dose is due

C. take simultaneously until the INR is within appropriate range

D. immediately

A. upon discontinuation (~2 hours)

When can you transition from LMWH to a DOAC?

A. upon discontinuation (~2 hours)

B. when next dose is due

C. take simultaneously until the INR is within appropriate range

D. immediately

B. when next dose is due

When can you transition from DOAC to a warfarin?

A. upon discontinuation (~2 hours)

B. when next dose is due

C. take simultaneously until the INR is within appropriate range

D. immediately

C. take simultaneously until the INR is within appropriate range

When can you transition from DOAC to a LMWH?

A. upon discontinuation (~2 hours)

B. when next dose is due

C. take simultaneously until the INR is within appropriate range

D. immediately

B. when next dose is due

If a patient's CrCl is <=60 ml/min, how can you determine when to check SCr again?

divide CrCl by 10, and that number gives you the number of months to follow up

-Ex: CrCl=40 ml/min

-40/10=4

-follow up in 4 months

How should the DOAC be managed in this scenario?

- dental intervention

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

A. does not necessarily require the discontinuation of anticoagulation

How should the DOAC be managed in this scenario?

- cataract or glaucoma intervention

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

A. does not necessarily require the discontinuation of anticoagulation

How should the DOAC be managed in this scenario?

- endoscopy without surgery

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

A. does not necessarily require the discontinuation of anticoagulation

How should the DOAC be managed in this scenario?

- superficial surgery

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

A. does not necessarily require the discontinuation of anticoagulation

How should the DOAC be managed in this scenario?

- endoscopy with biopsy

- prostate or bladder biopsy

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

B. hold DOAC 24 hours prior

How should the DOAC be managed in this scenario?

- radiofrequency catheter ablation for supraventricular tachycardia

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

B. hold DOAC 24 hours prior

How should the DOAC be managed in this scenario?

- angiography

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

B. hold DOAC 24 hours prior

How should the DOAC be managed in this scenario?

- pacemaker or ICD implantation

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

B. hold DOAC 24 hours prior

How should the DOAC be managed in this scenario?

- complex left sided ablation

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

C. hold DOAC 48 hours prior

How should the DOAC be managed in this scenario?

- spinal or epidural anaesthesia

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

C. hold DOAC 48 hours prior

How should the DOAC be managed in this scenario?

- thoracic surgery

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

C. hold DOAC 48 hours prior

How should the DOAC be managed in this scenario?

- abdominal surgery

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

C. hold DOAC 48 hours prior

How should the DOAC be managed in this scenario?

- major orthopedic surgery

A. does not necessarily require the discontinuation of anticoagulation

B. hold DOAC 24 hours prior

C. hold DOAC 48 hours prior

D. hold DOAC 72 hours prior

C. hold DOAC 48 hours prior

When can you resume a DOAC after a procedure? (select all)

A. 4-8 hours after

B. 6-8 hours after

C. immediate and complete hemostasis achieved

D. immediate but incomplete hemostasis achieved

E. re-bleeding risk is minimal

B. 6-8 hours after

C. immediate and complete hemostasis achieved

E. re-bleeding risk is minimal

If invasive procedure, resumption of DOAC may be deferred for _________

A. 24 hours

B. 24-48 hours

C. 36-72 hours

D. 48-72 hours

D. 48-72 hours

Which of the following are signs/symptoms of bleeding? (select all)

A. epistaxis

B. hematuria

C. hemoptysis

D. melena

E. hematochezia

A. epistaxis

B. hematuria

C. hemoptysis

D. melena

E. hematochezia

S/Sx of bleeding:

- hematocrit less than ________

A. 10%

B. 20%

C. 30%

D. 40%

C. 30%

note: or drop of more than 2-3% in 24 hours

S/Sx of bleeding:

- platelet count less than ________

A. 100,000

B. 200,000

C. 300,000

D. 400,000

A. 100,000

note: or greater than 50% drop from baseline

S/Sx of bleeding: (select all)

- new onset:

A. back pain

B. flank pain

C. head pain

D. groin pain

A. back pain

B. flank pain

D. groin pain

What needs to be taken at baseline for heparin monitoring? (select all)

A. weight, height

B. PT/INR

C. PTT

D. CBC

A. weight, height

B. PT/INR

C. PTT

D. CBC

Ongoing heparin monitoring:

- CBC every _______

A. 1-2 days

B. 1-3 days

C. 2-3 days

D. 2-4 days

B. 1-3 days

Ongoing heparin monitoring:

- Anti Xa level _______ hours after bolus and initial infusion

A. 3-6

B. 4-6

C. 6-8

D. 8-10

C. 6-8

Ongoing heparin monitoring:

- Anti Xa level _______ hours after dose changes until therapeutic

A. 3-6

B. 4-6

C. 6-8

D. 8-10

C. 6-8

Ongoing heparin monitoring:

- Anti Xa level 6-8 hours after bolus and initial infusion

- Anti Xa level 6-8 hours after dose changes until therapeutic

- Anti Xa level ________ thereafter

A. once daily

B. twice daily

C. once every other day

D. as needed

A. once daily

What is the purpose of the HAS-BLED score?

gives an assessment of the patient's risk of bleeding to determine if warfarin is an appropriate drug